ScribeAmerica classroom training final exam
Solved 100%
Different components of the SOAP note and what belongs in each section - ANSWER-
Subjective includes
- Chief Complaint (CC)
- History of Present Illness (HPI)
- Review of Systems (ROS)
In between subjective and objective is the Past history (PMHx, PSHx, SHx, FHx)
Objective include
- Vital Signs (HR, RR, BP, T, O2Sat)
- Physical Examination (PE)
- Orders and results
Assessment includes
- Diagnosis
- Description of progress since last visit
Plan includes
- Treatment and follow-up
Clinic Flow (5 general points) - ANSWER-1. Check-in
2. Physician Evaluation
3. Orders & Results
4. Assessment & Plan
5. Check-out
Clinic Flow (detailed) - ANSWER-Check-in
- Pt walks into the clinic (diagnosis vs. health management)
- Room placement
- Meaningful use obtained by Nurse/MA (CC, Vital signs, height/weight/BMI, smoking
status)
- Nurse/MA assessment:
1. Confirm CC
2. Review allergies/medications
3. Brief past medical history
Physician Evaluation
- Review the patient's medical records
- Assessment and plan from the previous visit
- Labs and/or imaging results
- History and Physical (H&P): HPI, ROS, PE
- Differential Dx (Possible Dx that may be causing the symptoms)
Orders and results
, - Orders
- Laboratory studies
- Imaging studies
- Procedures
- PT/OT (Physical therapy and occupational therapy)
- Results :May result during visit or in a few days
Assessment & Plan
- Assessment = The list of diagnoses
- Plan
- Follow-up with specialist if necessary
- Instructions for lifestyle and preventative care
- Follow-up for next routine appointment
Check-out
- Home vs. sent to the ED
- Patient education provided
- Patient will often stop at the front desk on the way out to schedule the next
appointment
Protected health information (PHI) - ANSWER-Refers to any type of information that
can be directly or indirectly tied to a particular patient or visit:
- First or last name
- Date of birth
- Medical record number
- Even the fact that the patient was seen in your clinic
Health Insurance Portability and Accountability Act and its 6 rules - ANSWER-A body of
laws designed to protect the private health information of patients across the country.
Has six rules
1. No cell phones or pictures
2. Someone is always watching
3. Never share your username and password
4. Ask yourself, "Do I need to access this for my job?"
5. Your job does not belong on social media
6. If a patient is not assigned to your doctor, do not touch the chart
Chief complaint and importance of the chief complaint - ANSWER-Main reason for the
visit, every level of billing requires a CC in order to be reimbursed for the service
provided.
Format of HPI (3 types) - ANSWER-The story of the chief complaint
3 formats
Simple Complaint Formula
- Structure is the most commonly used HPI structure and it is widely accepted across
multiple specialties.
Solved 100%
Different components of the SOAP note and what belongs in each section - ANSWER-
Subjective includes
- Chief Complaint (CC)
- History of Present Illness (HPI)
- Review of Systems (ROS)
In between subjective and objective is the Past history (PMHx, PSHx, SHx, FHx)
Objective include
- Vital Signs (HR, RR, BP, T, O2Sat)
- Physical Examination (PE)
- Orders and results
Assessment includes
- Diagnosis
- Description of progress since last visit
Plan includes
- Treatment and follow-up
Clinic Flow (5 general points) - ANSWER-1. Check-in
2. Physician Evaluation
3. Orders & Results
4. Assessment & Plan
5. Check-out
Clinic Flow (detailed) - ANSWER-Check-in
- Pt walks into the clinic (diagnosis vs. health management)
- Room placement
- Meaningful use obtained by Nurse/MA (CC, Vital signs, height/weight/BMI, smoking
status)
- Nurse/MA assessment:
1. Confirm CC
2. Review allergies/medications
3. Brief past medical history
Physician Evaluation
- Review the patient's medical records
- Assessment and plan from the previous visit
- Labs and/or imaging results
- History and Physical (H&P): HPI, ROS, PE
- Differential Dx (Possible Dx that may be causing the symptoms)
Orders and results
, - Orders
- Laboratory studies
- Imaging studies
- Procedures
- PT/OT (Physical therapy and occupational therapy)
- Results :May result during visit or in a few days
Assessment & Plan
- Assessment = The list of diagnoses
- Plan
- Follow-up with specialist if necessary
- Instructions for lifestyle and preventative care
- Follow-up for next routine appointment
Check-out
- Home vs. sent to the ED
- Patient education provided
- Patient will often stop at the front desk on the way out to schedule the next
appointment
Protected health information (PHI) - ANSWER-Refers to any type of information that
can be directly or indirectly tied to a particular patient or visit:
- First or last name
- Date of birth
- Medical record number
- Even the fact that the patient was seen in your clinic
Health Insurance Portability and Accountability Act and its 6 rules - ANSWER-A body of
laws designed to protect the private health information of patients across the country.
Has six rules
1. No cell phones or pictures
2. Someone is always watching
3. Never share your username and password
4. Ask yourself, "Do I need to access this for my job?"
5. Your job does not belong on social media
6. If a patient is not assigned to your doctor, do not touch the chart
Chief complaint and importance of the chief complaint - ANSWER-Main reason for the
visit, every level of billing requires a CC in order to be reimbursed for the service
provided.
Format of HPI (3 types) - ANSWER-The story of the chief complaint
3 formats
Simple Complaint Formula
- Structure is the most commonly used HPI structure and it is widely accepted across
multiple specialties.
